Means of Clinical Examination PDF

 MEANS OF CLINICAL EXAMINATION By Dr: Ahmed Mohamed Elgohary Lecterure of Oral Medicine, Periodontology, Oral Diagnosis& Dental Radiology Department Al-Azhar University, Assiut  Methods of collecting information I-Patient history II-Physic...

 MEANS OF CLINICAL EXAMINATION By Dr: Ahmed Mohamed Elgohary Lecterure of Oral Medicine, Periodontology, Oral Diagnosis& Dental Radiology Department Al-Azhar University, Assiut  Methods of collecting information I-Patient history II-Physical examination III-Adjunctive diagnostic procedures: Laboratory test Radiographic x-ray  Health Status Classification System by American Society of Anaesthesiologists Level l: Patient with no systemic disease. A level 1 patient should be able to run for 2 min without becoming short of breath. Level2: Patient with mild systemic disease. A level 2 patient should be able to walk two city blocks at a fast pace without becoming short of breath Examples of mild systemic disease: Well-controlled, non-insulin-dependent diabetes Well-controlled epilepsy, no seizures within 1-year period Well-controlled hypertension Level3: Patient with severe systemic disease. patient should be able to walk at a regular pace; however, physical activity will be limited. A level 3 patient will not be able to climb one flights of stairs without becoming short of breath or experiencing some discomfort. Examples of severe systemic disease: Insulin-dependent diabetes chronic bronchitis History of angina pectoris Anticoagulant therapy Prolonged steroid therapy Diastolic pressure of 105-114 mm Hg Level4: A patient with incapacitating or life- threatening disease. patient will be unable to do light activity and may experience discomfort while at rest. Examples of incapacitating systemic disease: Severe hypertension A diastolic pressure > 115 mm Hg Uncontrolled diabetes Unstable angina pectoris Acute myocardial infraction or a cerebro- vascular accident within the last 6 months Renal disease  Implications for Dental Treatment Relating to Health Status Level l: Patient can receive routine dental treatment, no modification necessary. Level 2: Routine dental treatment may require modification such as medical consultation, shorter treatment length, use of sedatives or antibiotic premedication. Level 3: Routine dental treatment but more complex treatment modifications indicated. Emergency treatment should be performed in a hospital dentistry setup. Level 4: Only emergency dental treatment is indicated. Whenever possible, dental treatment should be postponed until the patient's medical Clinical examination is the second phase of the diagnostic procedure. It helps the clinician to record objective findings (signs) relating to the patient's complaint and aids to confirm physically abnormalities. The findings of the examination should be recorded It starts from general physical examination, head and neck examination, intraoral examination to the examination of the lesion.  Means of clinical examination 1. Inspection 2. Palpation 3. Probing 4. Percussion 5. Auscultation 6. Olfaction 7. Aspiration  1- INSPECTION By using sense of Vision During patient inspection, the following additional rules must be taken in to consideration.  good light rules must Effective patient be taken position during inspection. washing of the lesion dental mirror , suction and tongue depressor The dentist should know the normal appearance of the tissues in order to assess abnormalities. The dentist should looked good for:  anatomical,  physiological psychological landmarks of his patient any deviation from the normal must be recorded.  By inspection the examiner records the color of the lesion Surface texture, contours of the lesion functional movement of some oral structure e.g. tongue. For example, the color of the lesions is an important character for the examiner as the following: The normal color of the oral mucosa include the range of pink taking into consideration any physiologic pigmentation that might be present. The white color indicate the presence of : more keratin in the epithelial surface, accumulation of surface depress pseudo membrane formation The red color indicate thinning of the lesions i.e. erosion or atrophy of epithelial surface and may be due to increase of vascularity of the underlying submucosa.  the yellow color indicate the presence of anemic pallor, increase the level of bilirubin “different type of jaundice” or increase level of carotene as in case of carotinemia. Brown, bluish or black discoloration indicates the presence of: exogenous pigment e.g. metallic intoxication endogenous pigment as melanin pigmentation or blood products, as Haemangioma. Reticular type of lichen planus at buccal mucosa Erosive areas on palate of lupus erythematosis patient Melanin pigmentation of the gingiva  2- PALPATION By using sense of Touch Palpation means clinical sense of touch to detect tissue abnormalities. Palpation is performed by compressing the examined tissues or structures between two fingers or two hands as in oral soft tissue e.g. tongue, lip and buccal mucosa compressing the tissues against the bone when the tissue are supported by bone e.g. attached gingiva  The tissues and structures of the oral cavity is variable in consistency.  it may be: osseous structures, muscular structures, lymphatic and glandular structures.  By palpation the dentist should record the surface of the lesion to be : rough or smooth hard or soft moist or dry fixed to the underlying structure “indurate” or mobile lesions. The palpation may be bidigital or bimanual Bidigital palpation: means manipulation of the examined tissues between two fingers of one hand of the examiner. Bimanual palpation: means examination of the tissue by using two hands or finger of both hands. Features that can be revealed by palpation include 1. Consistency 2. Mobility 3. Extent , Size and shape 4. Surface temperature  1. Consistency The following terms are commonly used to describe the consistency Soft: compressible under pressure as lipoma or mucocele. Firm: tissues cannot be easily compressed to pressure with minimal shape alteration occurs. Many benign neoplastic and hyperplastic enlargements are firm.  Hard: sensation of bony tissue and implies calcification Indurated: means hardness without calcification. Induration is a feature of many malignant neoplasm’s Spongy: minimal resistance to pressure and quickly regains the original contour after the pressure is released.  Pitting: tissue respond to pressure then slowly regains the original contour after release of pressure, e.g. edema Collapsing: easily compressible, remains deformed after the release of pressure.  2.Mobility Palpation reveals whether a mass is fixed or mobile in all direction Masses freely movable in all directions benign lesion AS epidermoid cyst. Masses fixed to all layers of tissue AS squamous cell carcinoma at this stage fixes the skin or mucous membrane to the deeper tissues.  3.Extent of the Lesion The lesion may have: ill defined borders (malignant lesion that infiltrates adjacent tissue). well defined borders (encapsulated). Size and shape of the lesion - Size can be easily determined by inspection - Round or ovoid masses are suggestive for cyst, benign tumor or lymph nodes. Irregular shapes are suggestive for malignancy  Bidigital palpation The good example of this type of palpation is the examination of some lesions affecting oral mucosa such as leukoplakia of the oral cavity, different types of lichen planes, gamma of the tongue and palate in tertiary stage of syphilis, median rhomboid glossitis and palpation of the submandibular lymph nodes.  gamma of the tongue and palate in tertiary stage of syphilis, median rhomboid glossitis  Bimanual palpation The good example is the examination of the floor of the mouth. The technique of this type of palpation as the following: The examine index finger of one hand should express the floor of the mouth while, the opposing finger of the other hand compress the tissues to detect salivary gland calculi Palpation of the tempromandibular joint Use light pressure. Place your finger just anterior to the tragus of the ear. Instruct the patient to slowly open, close, and move the mandible from one side to another “bimanual”. Palpation of submandibular area Instruct the patient to tilt her head pack slightly and carefully palpate the submandibular area “bimanual”. Palpation of submental area Instruct the patient to bite together tightly and place the tongue into the palatal fold, this will result in stretching of the mylohyoid muscle. The dentist can palpate the submental soft tissues against the muscle.  3- Percussion Percussion means striking of the tissues by an instrument to listen to the result sounds and also to evaluate the reaction of the patient to percussion i.e. painful or not. Percussion as one of means of clinical examination is used for evaluation and localization of the inflammatory condition involving the teeth and supporting Technique of teeth percussion: Striking of the cusp or incisal edge of each tooth. The examiner should use a gentle stroke of instrument with blunt end e.g. explorer No 17. The blow of percussion should be directed to the long axis of the tooth. Tooth with healthy periodontium exhibit solid sound on percussion, while the tooth with any pathologic condition the dentist feel dull sound on percussion. Apical percussion to detect the preapical lesion. Lateral percussion to detect the periodontal condition. Technique of muscles and bone percussion: Percussion of the muscles and bone done by sharply tapping on the area to be examined with the tip of two or three fingers. By this technique the clinician can obscure the muscles reflex mechanisms and tenderness.  In patient with hypoparathyrodism “Tetany” the percussion can be performed by tapping over the facial nerve in front of the ear, the results will be twitching of the facial muscles (chivostek’s sign)  4- Auscultation Auscultation means listening for sounds within the organ e.g. heart or structure as tempromandibular joint. In dentistry the auscultation as one of clinical examination means is commonly used during examination of tempromandibular joint e.g. TMJ clicking TMJ snapping and TMJ  5- Probing The probing mainly restricted on detection of carious lesion of the teeth or detection and measurement of pocket depth , so this technique is most commonly used during intra-oral examination. Probing of the teeth is performed by use of dental explorer, and measurement of pocket depth by use of calibrated or graduated periodontal probe.  Olfaction-6 The sense of smell occasionally contributes to diagnostic information as: Fetid odor of bacterial infection ANUG. Garlic or bad odor of chronic periodontitis. Acetone odor in diabetes. Urine smell in renal failure.  7-Aspiration Withdrawal of fluids from body cavity. Aspirate used for cultures and sensitivity tests to identify the pathogen E.g. Heamangioma bluish blood is aspirated. Yellowish white fluid “pus” (associated with painful fluctuant swelling) abscess. Yellowish white fluid pus with “sulphur granule” Actinomycosis